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«Vision therapy and Neuro-rehabilitation are used to treat specific diagnosed ocular, visual and visual perceptual conditions. In some cases, vision ...»

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Insurance, Vision Therapy, and Harvey Richman, O.D., FCOVD

Jason Clopton, O.D., FCOVD

Neuro-Optometric Rehabilitation… Richard Soden, O.D., FCOVD

Vision therapy and Neuro-rehabilitation are used to treat specific diagnosed ocular, visual and visual

perceptual conditions. In some cases, vision therapy is the only available and effective treatment

option for those conditions. Treatment may be covered under major medical or vision insurance plans. An important consideration of managing a vision therapy practice is to appropriately code for all patients, whether using insurance or not.

Reimbursement of Optometric Vision Therapy This information packet has been developed to assist individuals involved with medical insurance claims processing and review to better understand the application and utilization of optometric vision therapy. Although vision therapy is not a new area of medical care, information gained from scientific research and clinical application of vision therapy has been expanding in recent years.

Optometric vision therapy has been shown to be an effective treatment modality for many types of problems affecting the vision system. Vision therapy services include the diagnosis, treatment and management of disorders and dysfunctions of the vision system including, but not limited to, conditions involving binocularity, accommodation, oculomotor disorders and visual perceptual-motor dysfunctions. However, the exact length and nature of the therapy program can vary with the specific complexity of the diagnosed condition.

This packet contains fact sheets regarding the treatment and management of various conditions with optometric vision therapy. Because of the differences in complexity of conditions and management approaches, this information should be used only as a guideline. Ultimate responsibility for the correct submission of claims and responses to any remittance advice lies with the provider of services.

 Coding Background Understanding what codes optometrists should use and their respective definitions is most important in all coding. The entire coding and medical industries are dependent upon accurate code use and interpretation to allow information to be accurately transferred between the provider and the payer.

All of the codes used by optometry are also used by general medicine and/or other specialty providers. Coding and billing in an optometric office is performed using code sets established and maintained by different entities. The code sets used in this process include: the ICD-9 Clinical Modification code set, the Current Procedural Terminology code set – which is usually called “CPT,” and the health care common procedural coding system or HCPCS (pronounced “hick picks”) code set. Each code set has a specific purpose in the billing process.

These standard code sets used in optometric practices have specific purposes. They consist of the ICD-9 CM codes for diagnoses, the CPT© codes for most procedures and the HCPCS Level II codes for procedures and products not covered under the CPT © umbrella. Most carriers have published policies that follow the CPT© closely, although it's not uncommon to find that they may have specific policies or guidelines that build on the CPT © definition for a particular code. At the current time, ICDCM is developed to allow for greater classification of morbidity and mortality within diagnoses for ® AOAExcel™ is a wholly owned subsidiary of the American Optometric Association.

physicians, but is not being utilized within the United States. It is expected to be implemented in October 2014.

All of these code sets are standardized nationally. The Healthcare Insurance Portability and Accountability Act (HIPAA) prohibits the use of proprietary codes that were previously developed and used by local carriers and insurers and provider groups. It also stipulates that all codes are to be used as they are defined and not to report additional services that are not currently included in the definition.

There are regional Medicare and third party insurance company’s policies regarding coverage decisions about what items or services are reasonable and necessary. Often they elaborate on procedural codes rather than simply relying on the CPT© definition. These policies are generally available on the carrier's web site or provider manual and are referred to in current nomenclature as Local Coverage Determinations (LCDs) by CMS or clinical policy bulletins, medical coverage policy medical coverage determinations by the major national third party payers. Whatever acronym or name used, they serve the same function in defining the appropriate guidelines in using a particular code.

Delivering quality healthcare depends on capturing accurate and timely medical data. Medical coding professionals fulfill this need as key players in the healthcare workplace.

Health information coding is the transformation of verbal descriptions of diseases, injuries, and procedures into numeric or alphanumeric designations. Originally, medical coding was performed to classify mortality (cause of death) data on death certificates. However, coding is also used to classify morbidity and procedural data. The coding of health-related data permits access to medical records by diagnoses and procedures for use in clinical care, research, and education.

There are many demands for accurately coded data from the medical record. In addition to their use on claims for reimbursement, codes are included on data sets used to evaluate the processes and outcomes of healthcare. Coded data are also used internally by institutions for quality management activities, case-mix management, planning, marketing and other administrative and research activities.

 What codes should I use?

There are only a finite number of codes you will use in the vision therapy portion of your practice.

These codes can be subdivided into: examination procedure codes, diagnostic codes, and therapeutic procedure codes. In all of the code choices, the most important factor is documentation. If you have the documentation needed to support the history, examination, treatment plan and medical decision-making requirements, you may have several codes to choose between.

The primary rule of documentation is, “if it wasn’t written, it never happened.” In the instance where the documentation is present, you can choose procedure codes based on what is covered, what is permitted, and/or what reimburses appropriately for your time. It is not a search for the highest reimbursing code, because often the higher reimbursement requires additional non-patient care work including multiple written reports and lots of staff time to get approval. Often, the end result after factoring in all these costs may be a lower reimbursing net.

® AOAExcel™ is a wholly owned subsidiary of the American Optometric Association. 2 Coding is a complex area for all healthcare providers, and this is no less true for optometrists. It is strongly suggested that you use all resources available when you are attempting to code correctly for insurance filing, and this chapter is intended only as an introduction to the topic. The key to everything else about coding is that your chart completely supports the codes that you used according to the definitions listed by CPT©. If you choose to accept insurance in your vision therapy practice, knowledge of your local carriers and their particular requirements is critical to success. Once you have that knowledge, use it to create a consistent, solid pattern of documentation in your records and assume that every time you document, what you have written will be seen by an auditor.

 What examination procedure codes should I use?

The American Medical Association owns the CPT© codes. There are several evaluation and management procedural codes that could be used for an office visit to determine if the patient has an ocular, visual or visual perceptual problem. They would include 92002, 92004, 92012, 92014, 99201or 99211-99215. These codes are defined as comprehensive general ophthalmologic examination codes (92004 and 92014), intermediate general ophthalmologic examination codes (92002 and 92012) and the evaluation and management codes (99201-99205 and 99211-99215).

You can use these codes in multiple combinations on different days if it best describes the procedures you are doing (please refer to the chart at the end of this chapter). An example of this would be for a patient seen in the office today for a 92004 (comprehensive general ophthalmologic examination-new patient). Tomorrow the same patient is scheduled for a 92012 (intermediate general ophthalmologic examination-established patient) and then, next week is scheduled for a 99213 (evaluation and management exam of an established patient). It would be incorrect coding to use these procedure codes simultaneously on the same day.

Other procedure codes to consider are consultation codes. A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. These are the 99241-99245 codes. Usually, these codes are only to be used on the patient’s first visit to the office after the physician or other appropriate professional made the referral. Occasionally, the consultation codes can be used on established patients when there was a request for new information from the referring doctor. Consultation codes must have documentation that includes correspondence from the doctor requesting the consultation. Recently the outpatient consultation codes have begun to be phased out by third party payers.

If the patient is coming to you for a “consultation” initiated by a patient and/or family member, and not requested by a physician, you should use the evaluation and management codes 99201-99205.

 What special testing codes should I use?

After determining the patient needs additional testing, you have several coding options: 92060 (sensorimotor exam), 96110 (developmental testing; limited), 96111 (developmental testing), and 96116 (neurobehavioral status exam). These codes can be used in combinations with evaluation and management codes, by themselves or with each other to best describe the procedures you are doing.

CPT© describes the diagnostic test 92060, as Sensorimotor examination with multiple measurements of ocular deviation (e.g., restrictive or paretic muscle with diplopia) with interpretation and report ® AOAExcel™ is a wholly owned subsidiary of the American Optometric Association. 3 (separate procedure). Fundamentally, this test requires the clinician to assess both eyes (i.e., bilateral); it should not be billed per eye. Pertinent diagnoses include but are not limited to: diplopia, exotropia, esotropia, hypertropia and paralytic strabismus.

A basic sensorimotor exam evaluates ocular range of motion to determine if the eyes move together in the various cardinal positions of gaze (12:00, 1:30, 3:30, etc). This exam element is commonly noted as ocular motility, or extraocular muscles (EOM), in the chart note. A normal range of motion is often noted as "full" or "within normal limits."

CPT© lists basic sensorimotor exam as a required exam element of a comprehensive eye exam (920×4); it is an incidental component and not separately reimbursed. A quantitative sensorimotor examination, utilizing prisms to measure ocular deviation, is a more extensive exam and may be separately billable.

The American Association for Pediatric Ophthalmology and Strabismus (AAPOS) issued a position statement in 1999. They state, "Sensorimotor eye exam includes measurement of ocular alignment in more than one field of gaze at distance and/or near, and inclusion of at least one appropriate sensory test in patients who are able to respond." Measuring only primary gaze at distance would not satisfy the requirements. You should include ocular alignment measurements in more than one field of gaze.

According to sources at AAPOS, primary gaze at distance and near for accommodative esotropia would satisfy the criteria.

Examples of sensory function testing include Worth 4 dot, Maddox rod, and Bagolini lenses. The assessment of sensory function is complementary to the evaluation of the motor function as the term "sensorimotor" implies. It is no less important and an essential part of the service.

 How is the sensorimotor exam documented in the patient's medical record?

An order for the test should be noted in the chart. Test results for motor function are typically documented in a "tic-tac-toe" format to represent different fields of gaze. Results of the sensory function test are noted, too. Examiners note how many of the stereo rings on the Titmus Fly test are correctly observed by the patient and whether or not the patient appreciated the three-dimensional appearance of the fly's wings. A positive stereo test on a nonverbal patient might be represented by the patient's attempt to touch or pick up the fly's wings. Results of a Worth 4 dot often note which lights were seen. An interpretation of the test results and the effect on the patient's condition and course of treatment satisfy the interpretation requirements. Take care that the notations for the test are clearly identifiable and distinct from the office visit notes (e.g., stamp, boxed entry, separate page, etc.).

Repeated testing is indicated when medically necessary for new symptoms, disease progression, new findings, unreliable prior results or a change in the treatment plan. In general, additional testing is warranted when the information garnered from the eye exam is insufficient to adequately assess the patient's disease. For example, if a patient has a history of accommodative esotropia and the basic sensorimotor exam reveals an unstable or worsening condition, the more extensive test is justified.

The insurance carriers would not expect a claim for a stable patient who presents with no complaints or one with a controlled condition.

The specific 96000 CPT© codes used by physicians are used to report the services provided during testing of the cognitive function of the central nervous system. The testing of cognitive processes, visual motor responses, and abstractive abilities is accomplished by the combination of several types ® AOAExcel™ is a wholly owned subsidiary of the American Optometric Association. 4 of testing procedures. It is expected that the administration of these tests will generate material that will be formulated into a report.

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